Is Radiation the way to go

[realtorjohn42]

Hello all,

My question: Is radiation treatment the way to go? I am newly diagnosed with Biochemical Recurrent PC.

From Dr. Childs notes:Date of diagnosis: 4.28.15 Stage: T2c, N0, MX Gleason grade: 7 (3+4) after RP

Date of last biopsy: 4.28.15 PSA density: PSA: doubling 4.3 months

Genetic testing performed and result: OncotypeDX 35, 30% chance of unfavorable pathology

Primary Cancer treatment: S/p RALRP (Kuhn) (09.18.15)

Most recent cancer staging imaging date and results: MRIp and WBB 2.2020 negative for disease

PSA trend: 0.212 (6.18.20), 0.2 (4.30.20), 0.12 (2.19.20) 0.164 (1.27.20), 0.111 (11.13.19), 0.1 (10.30.19), 0.06 (12.19.18), 0.05 (6.20.18), 0.03 (12.18.17), 0.02 (5.30.17), 0.01 (11.30.16), 0.01 (8.30.16), 0.01 (4.20.16), 0.00 (1.20.16), 0.02 (10.19.15).

*Axumin scan has been denied a few times due to PSA < 1.0

Assessment:

1. Prostate Cancer: Pros Bx (MAC) (04.28.15): 5 cores Gleason 7(4+3); S/p RALRP (Kuhn) (09.18.15), Path: Gleason 7(3+4); Stage: T2c, N0, MX; The right soft tissue/capsular margin is focally involved by tumor. Last PSA: 0.12 (2.19.20) down from 0.164 (1.27.20) Patient has recovered urinary and sexual function.

* Since prior visit, pt has seen Dr. Wang for evaluation of radiation tx. Dr. Wang recommended pt begin IGRT with adujuvant ADT x 6 months

2. Hypogonadism: Not treating due to BCR. Decreasing. Last testo: 250 (6.18.20), 247 (4.30.20), 224 (10.30.19), 265 (12.19.18)

2. Microscopic hematuria: Asymptomatic. UA clear (1.30.20); Trace-intact blood per UA (12.19.18)

Data:

- UA (1.30.20) Clear

- UA: blo/negative (10.30.19)

- PSA: 0.212 (6.18.20), 0.2 (4.30.20), 0.12 (2.19.20) 0.164 (1.27.20), 0.111 (11.13.19), 0.1 (10.30.19), 0.06 (12.19.18), 0.05 (6.20.18), 0.03 (12.18.17), 0.02 (5.30.17), 0.01 (11.30.16), 0.01 (8.30.16), 0.01 (4.20.16), 0.00 (1.20.16), 0.02 (10.19.15)

- PSA: doubling 4.3 months - Prostate size: 52.2 cc

- Testosterone: 250 (6.18.20), 247 (4.30.20), 224 (10.30.19), 265 (12.19.18)

- Vitamin D 25-hydroxy: 27.0 (4.30.20)

- Alkaline Phosphate: 70 (6.18.20), 58 (1.27.20)

- LDH: 143 (4.30.20), 145 (1.27.20)

- CT A/P (01.25.19): negative for mets. 3.2 cm infrarenal abd aortic aneurysm

- NM Bone Scan (02.06.19): no evidence of skeletal mets

-MRI prostate fossa 2.12.20: negative

- NM Bone Scan (2.25.20): no evidence of skeletal mets

- OncotypeDX 35, 30% chance of unfavorable pathology

Plan:

- Discussed current and previous sxs.

-insurance has denied Axumin

- Discussed PSA trends today, scan negative; R1 on path and PSAV suggest local recurrence; I am in favor of salvage tx given his young age/life expectancy and his preference and desire to avoid ADT long term.

- Discussed IGRT for tx for prostate cancer - procedure details, risk, and benefits reviewed.

- Discussed 6 months of ADT for tx of prostate cancer - procedure details, risk, and benefits reviewed.

- Recommended that pt perform ADT alongside IGRT for tx for prostate cancer.

- Discussed Lupron Q-6 months vs. Firmagon Q-1 month for ADT tx. Patient had interest in Firmagon to start but has elected Lupron

- Discussed Axumin scan procedure; insurance has previously denied. - procedure details, risk, and benefits reviewed Pt is interested in cash pay, but I think there is a lower chance it will change management given his history

- 6 month Lupron today.

he would like IGRT locally and wants to go to Landmark, will refer to Foster Lasley MD

So I am going to meet RO Dr. Lasley today for a consult. I welcome any and all advice on my current situation and how best to navigate my treatment going forward.

Thank You in advance,

John

[Hidden]

Great job recording your info. I was dxed 3-15 myself . Please let us know what the dr says? Others will chime in with Expert treatment advise . You look very young in the photo. May I ask your age please ? I have no doubt that You will choose what is best for yourself and get on with it ,I say “ Hit it with the kitchen sink if need be” .. Good health to you Sir ! 🌵😎

[realtorjohn42 in reply to Hidden]

Yes thank you Whimpy-p! The photo is old. I am 63

[Hidden in reply to realtorjohn42]

Great photo !

[Hidden]

It is understandable that Axumin is denied as it will probably find nothing at your current PSA. You may have a 40-50% detection rate with PSMA if you can afford to pay out of pocket. Your PSA during 2020 is fluctuating a lot so absolute level and PSADT time should not considered as curved in stone.

PS

I run your PSA numbers taking as the start of the time series the big discontinuity of 0.06 to 0.1 registered on 30 Oct 2019.

Linear regression gives 6.9 months DT and exponential regression 7.1 months. The norm is the exact opposite, i.e. the exponential regression is usually SHORTER than the linear. Your numbers do not depict the average BCR. I am not saying that you are not undergoing BCR, which you obviously are, BUT that it is not as fast proceeding and according to the book as you may be thinking.

[realtorjohn42 in reply to Hidden]

Yes I agree with your assessment of my doubling time, and at the same time get on with it!

Thank You, justfor!

[Tall_Allen]

I don't understand why there is any doubt - please explain.

[realtorjohn42 in reply to Tall_Allen]

Just a little trepidation on my part I believe. After my Dr. visit yesterday, we are going to get on with it and knock this out the best way we know of. 39 treatments 70.2 Gy, Here we come! Thank You TA!

[immunity1]

If it was me I would go for salvage RT to the prosteate fossa as you have BCR but there will be side effects, hopefully mild. The alternative of no radiation is reasonable I suppose if QOL trumps logevity for you.

[realtorjohn42 in reply to immunity1]

I agree totally, and have gotten past the uncertainties. Will start treatments in about 3 weeks. Thank You, immunity1

[MateoBeach]

Yes young man, go for that IMRT. I trust your chosen facility has state-of-art technology for most precise targeting of radiation field and best protection for nearby "organs at risk". This should be asked about. Certainly great advantages in being treated locally for such a course of treatment, but not to compromise precision of delivery. Should be image guided (by rapid CT scan) and adjust positioning at beginning of every treatment.

The other question is whether to irradiate the pelvic lymph nodes at the same time. I do not see this mentioned so they may be planning salvage RT to the prostate fossa only. I do wish I had received treatment of PLNs back in 2007 when I had my SRT. I don't know that there is a hard and fast answer vs. waiting. But it is worth discussing while treatment is in planning stage. You have a chance for cure with this. Good luck John.

[realtorjohn42 in reply to MateoBeach]

Hi MateoBeach,

Yes the local facility will be using cone beam ct scan before every treatment.

My first RO consult was not going to treat the pelvic lymph nodes, but this one locally plans to treat the pelvic lymph nodes on the first 25 treatments with 45 Gy and 70.2 to the prostate fossa on the 39 treatment plan.

Thank You Very Much!

[fluffyfur]

My husband just started VMAT. 35 treatments total at 2 gy each. No ADT though and prostate bed only. He is feeling tired. That's his only side effect so far. His pathology was similar to yours, G7 positive margins. Is your RO going to radiate your nodes?

[realtorjohn42 in reply to fluffyfur]

Hi Fluffyfur,

Yes the plan is 6month Lupron ADT with 39 treatments at 70.2 Gy ( Varian 2100 IX) with the first 25 treatments treating the Pelvic lymph nodes at 45 Gy .

Thank You for the reply it is very helpful!

[caltexman]

You should have great results from Salvage radiation. I finished a year ago. I scheduled treatments at 5 PM and walked for an hour right after each treatment. The hardest part was filling my bladder 30 minutes before the treatment and racing to the restroom when it was over.

[realtorjohn42]

Hi caltexman,

Thank You for the reassuring reply. It really helps!

I appreciate you!

Thank you and stay well!